Health Assessment Exam 3 Flashcards
What is mental health?
Cognitive functioning: thinking, knowledge, problem-solving
And
Emotional functioning; feeling mood behaviors, stability
- mental health can affect multiple body systems
Why is mental health important?
Mental health is a part of a persons, total health
It allows a person to think clearly, respond appropriately, function effectively in ADLs
What are other names for a mental disorder?
Mental illness
Psychiatric disorder
Psychiatric illness
Psychological disorder
According to WHO
What is mental health?
-Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with enormous stresses of life, can work productively, and is able to make a contribution in his/her community. It is not merely an absence of disease or infirmity
According to American Psychiatric Association
What is a mental disorder?
Any condition, which is characterized by cognitive and emotional disturbances, abnormal behaviors, impaired functioning, or any combination of these.
When there are problems with the mind (thoughts) and their mood (feelings)
What things contribute to a mental disorder?
External:
-environmental conditions
-Chemicals
-Social factors (socioeconomics)
-culture
-spirituality
-lifestyle choices
-exposure to violence
Internal
-genetics
-Psychological disorders/development
-personality factors
-spiritual factors
-neurological systems / damage to them
Who has the highest incident of mental disorder?
LGBT youth
What is a nurses role in mental health?
Initial assessment which includes
-Screening for past and present mental condition
-Observation
-Communication
-Administering questionnaires
-Ensuring information from results
-referrals
Substance abuse regarding mental disorder
-one of the most persistent conditions affecting mental health
-substance abuse can lead to dependence syndrome
-substance abuse can become a priority in people’s lives
Substance abuse: marijuana
Regarding mental illness
-legalization has created more issues
-misuse can lead to other substance abuse
-there are different varieties available with different THC levels
Cultural considerations regarding mental illness
-Substance abuse, violence, HIV, risk, depressive symptoms, and Socio economic conditions are directly linked to health disparities among Latinas
-Eye contact and facial expression may differ among cultures
-Perception of illness especially illness associated with mood and mental status vary across cultures
(culture bound syndromes)
What type of subjective data do you collect during a mental status assessment?
-appearance
-General behavior
-Cognitive function
-Memory
-Thought process
-The use of questionnaires/tests
-Biographical data
-History of present health concern
-Personal health history
-Family history
-lifestyle and health practices
What is biographical data and collecting a mental health history
-Name
-Address
-Phone number
-Age
-Date of birth
-Gender
-Gender identity
-Marital status
-Education level
-Employment
What questions do you ask when collecting a history of present health concerns for mental illness?
-What is the most urgent health concern?
-Why are you seeking health care?
-Do you have any other problems?
-Do you have headaches?
-trouble breathing?
-heart palpitations?
-insomnia?
-irritability/mood swings?
-Fatigue?
-suicidal/homicidal thoughts?
-Hallucinations?
What questions do you ask when collecting a personal health history for mental illness?
-have you received medical treatment!
-Have you been hospitalized before?
-Have you received counseling before?
-Do you have a history of head injury, meningitis, encephalitis, stroke?
-Have you ever served an active duty military? (TBI)
What questions do you ask when collecting a family history for mental illness?
-do you have a history of mental illness?
-Any health problems, such as anxiety, depression, bipolar, schizophrenia
-Any family history of dementia?
What lifestyle/health practices can affect mental illness?
-What is a typical day like?
— does your health concern affect your ADLs?
-What is your energy level?
-What are your usual eating habits over 24 hour period?
-What are your bowel patterns?
-What are your sleep patterns?
-What are your exercise regiment?
-Do you drink caffeine, how much?
-Do you drink alcohol, how much?
-Do you take any prescribed or OTC meds?
-Do you take any opioids?
What objective data do you collect during a mental health assessment?
-level of consciousness
-mental status
-cognitive abilities
What are the different levels of consciousness?
Stuporous
Coma
Obtunded
Lethargy
What objective data do you collect when assessing the mental status portion of a mental health assessment?
-Posture, gait, body movements
-behavior and effect
-Dress and grooming
-Hygiene
-Facial expressions
-speech
-Mood, feelings, expressions
-Thought process and perceptions
What objective data do you collect when assessing the cognitive abilities portion of a mental health assessment?
-orientation
-Concentration
-Recent memory
-Remote memory
-Use of memory to learn new information
-Abstract reasoning
-Judgment
-Visual, perceptual, and constructional ability
-Mini cog
-SLUMS dementia / Alzheimer’s test exam
How do you conduct a mini cog test?
1) instruct the client to remember three unrelated words, and repeat them back
2) instruct client to draw the face of a clock and note certain times by drying hands of the clock
3) ask the client to repeat three previously stated words
What questionnaires are used when assessing level of consciousness
-Glasgow coma scale
-mini cog
What is / How do you use SLUMS (st. Louis University mental status)
-an examination tool used to assess confidence function for dementia/Alzheimer’s
-the lower the score, the more likely to have dementia.
WITH HS DIPLOMA
30-27 = Normal
26-21 = Mild
20-1 = Dementia
NO HS DIPLOMA
30-25 = normal
25-20 = mild
19-1 = dementia
Explain when, and how to use the CAGE self assessment tool
C: cut: have you ever felt you should cut down on alcohol intake?
A: annoyed: have people annoyed you like criticizing you’re drinking?
G: guilty: have you ever felt bad or guilty about drinking?
E: eye-opener: have you ever had a drink first thing in the a.m. to study nerves, or to get rid of a hangover?
-Assesses a persons dependency on alcohol
-used with alcohol testing to identify at those clients
-has also been used to detect alcohol dependence in trauma center populations
-yes/no answers: each, yes, will increase the risk of alcohol dependency
Interview questions to assess psychosocial and why to ask them?
-how old are you?
-what is your birth date?
-Gender
-which gender do you identify?
Why?
-information helps determine reference point with which their psychosocial developmental level and appearance can be compare d
-women have higher risk of depression and anxiety
-men have a higher incidence of substance abuse and psychological disorders
Interview questions to assess moral development?
-do you have suicidal thoughts
-do you have through did wanting to hurt or kill anyone?
-do you have hallucinations? (What do you see/hear?)
-do you hear voices? (Do they tell you to hurt yourself or others?)
How to conduct a general screening for mental status and risk for substance abuse?
-observe level of consciousness
-Observe posture, Gait, body movements
-Observed behavior and effects
-Ask if they drink alcohol, type and how often
-Ask if they use illicit drugs, type, and how often
-Dress and grooming
-Facial expressions
-Speech
-Mood, feelings, expressions
-Thought processes and perceptions (any self injuries or Suicidal Tendencies)
-Orientation
-Concentration
-Reset and remote memory
How to conduct a focused screening for mental status and risk for substance abuse?
All the questionnaires…
PHQ-9 (assess depression)
-quick inventory of depressive symptomatology
-C-SSRS (suicidal risk)
-SBIRT (identify, reduced, prevent abuse of drugs/alcohol)
-ADIT (alcohol related disorders)
-generic, depression, scale
-SAD PERSONS
-Abstract reasoning
-SLUMS (Alzheimer’s/dementia)
-Judgment ability
-Visual, perceptual, and constructional ability
-Delirium verse other cognitive impairment (identify the cause of confusion)
What is the Glasgow coma scale?
GCS
1) eye-opening response
-Spontaneous opening (4)
-To verbal command (3)
-to pain (2)
-no response (1)
2) most appropriate verbal response
-Oriented (5)
-Confused (4)
-Inappropriate words (3)
-Incoherent (2)
-no response (1)
3) most integral motor response (arm)
-obeys verbal commands (6)
-Localizes pain (5)
-Withdraw from pain (4)
-flexion (3)
-Extension (2)
-no response (1)
How to use AUDIT (alcohol use disorder is identification test)
Interview the client for alcohol abuse
Use the following questions:
-How often do you have a drink containing alcohol?
-how many drinks contain alcohol? Do you have on a typical day when you were drinking?
-How often do you have 5 or more drinks on one occasion?
-how often during the past year have you found that you were not able to stop drinking once he has started?
-How often during the past year have you failed to do what was normally expected from you because of drinking?
-how often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
-how often during the past year have you had a feeling of guilt or remorse after drinking?
-How often during the past year have you been unable to remember what happened the night before because you had been drinking?
-have you or someone else been injured as a result of your drinking?
-Has a relative or friend or doctor or another health care worker been concerned about your drinking or suggested you cut down
Cause and confusion: to assess for causes of confusion in a client
What are the 6 areas
1) duration
2) onset
3) attention
4) memory
5) alertness
6) thinking/judgment
Cause and confusion: to assess for causes of confusion in a client
(6) answers for Dementia
For Dementia
1) Duration: chronic (does not resolve)
2) Onset: chronic
3) Attention: generally normal attention
4) Memory: recent and remote memory impaired
5) Alertness: generally normal alternates
6) thinking/alertness: may have word finding difficulties, judgement may be poor
Cause and confusion: to assess for causes of confusion in a client
(6) answers for Delirium
For Delirium
1) Duration: hours to weeks
2) Onset: acute onset
3) Attention: impaired/fluctuating attention
4) Memory: recent and immediate memory impaired
5) Alertness: fluctuates between lethargic and hypervigilant
6) thinking/alertness: disorganized thinking, slow or accelerated
Cause and confusion: to assess for causes of confusion in a client
(6) answers for Depression
For Depression
1) Duration: can last weeks to months or years
2) Onset: often abrupt onset
3) Attention: distractingly but minimal impairment of attention
4) Memory: island of intact memory
5) Alertness: alert
6) thinking/alertness: thinking intact though with themes of helplessness or self-prediction
What is the quick inventory of depressive symptomology?
A self report that is used to assess for indications of depression and a client
Patient will select one response to each item that is most appropriate to how they have been feeling over the past 7 days
-find asleep
-Sleep during night
-Waking up too early
-Sleeping too much
-Feeling sad
-Decreased appetite/increased appetite
-Decrease wait/increase weight
-Concentration/decision making
-Perception of self
-Thoughts of own death or suicide
-General interest
-Energy level
-Feeling more sluggish than usual
-Feeling restless (agitated, not relaxed, fidgety)
What is SAD PERSONS?
suicide risk tool to assess a client suicide risk
S = sex
A = age
D = depression
P = previous attempts
E = ethanol abuse (alcohol)
R = rational thinking loss
S = Social supports lacking
O = organized plan
N = no spouse
S = sickness
What are abnormal findings in level of consciousness
-Stuporous
-coma
-Obtunded
-Lethargy
-Decerebrate posture: hands down and flexed out
-Decorticate posture: hands clenched and brought up towards body
What are abnormal findings in sources of voice and speech problems?
-Dysphonia
-Cerebellar dysarthria
-Dysarthria
-Aphasia
-Wernicke aphasia
-Bracha aphasia
How to use clinical judgments when analyzing mental status and substance abuse risks
1) select the clients concerns
-Opportunity to improve health
-Risk for client concerns
-actual client concerns
2) selected collaborative problems that need to be monitored and treated by both nursing and primary healthcare provider
-Cluster cues to detect potential collaborative problems
-Monitor
3) referral to primary care provider for sudden, memory loss, and extreme confusion
-notice if signs and symptoms require psychiatric medical diagnosis and treatment for primary care provider as necessary
What is important for communicating interview in assessment findings for mental illness for documentation
-make sure to validate all collected data
* ask extra questions if needed
* verify data with another healthcare, professional
* compare, subjective, and objective findings
* verify data is reliable an accurate
-Document following healthcare facility or agency policy
-Document assessment findings by describing patient response instead of labeling the behavior
-Use SBAR
Describe the focus of the different theorists and developmental theories (3)
Erickson = psychosocial
Piaget = Cognitive
Kohlberg = Moral
What are the two main concepts that developmental theories are based on?
Growth: addition of new skill or components
Development: improvement of existing skills or components
What is Erickson’s developmental theory
-Psychosocial: intrapersonal and interpersonal responses of a person to external events
-Believe that a persons personality continues to evolve throughout their life
Influenced by : society, culture, history, biophysical, cognitive
8 stages
What are the eight stages of Ericksons developmental theory?
1) infant: trust vs mistrust
2) toddler: autonomy vs shame and doubt
3) preschooler: initiative vs guilt
4) school aged: industry vs inferiority
5) adolescent: identity vs role confusion
6) young adults: intimacy vs isolation
7) middle-age: generatively Vs stagnation
8) older adult: integrity vs despair
What is Ericksons infant stage
Infant: birth - 1 year
Stage: trust vs mistrust
Learning to trust self, others, and the environments
If an infant does not pass this stage (or has a negative resolution) they become suspicious / fearful
If an infant passes this stage (or has a positive resolution) they develop drive and hope to
What is Stuporous?
awakes to vigorous shake, or painful stimulus, but returns to unresponsive sleep
What is Obtunded ?
opening eyes to loud voices, responding slowly with confusion, seeming unaware of environment
What is coma?
remaining unresponsive to all stimuli, eyes stay closed
What is lethargy?
opening, eyes, answering questions, and falling back to sleep
What questionnaires are used to assess depression?
-PHQ – 2
-PHQ – 9
-quick inventory Depressive symptomatology (Self report) *over the past 7 days
-generic depression scale
What questionnaires would you use to asses risk for suicide?
-C-SSRS (Columbia suicide, severity, rating scale)
-Sad persons (suicidal risk assessment tool)
What questionnaire is used to asses drug/alcohol abuse?
-CAGE
-AUDIT (alcohol use disorder, identification test)
-Clinical institute withdrawal assessment scale
-SBIRT (screening, belief intervention, and referral to treatment )
What questionnaire is used to assess for PTSD
-DSM-5
What questionnaires are used to assess dementia/Alzheimer’s?
-SLUMS ST. LOUIS UNIVERSITY MENTAL STATUS
What is the PHQ-2
Questionnaire to assess depression. Asking two questions:
During the past month, have you often been bothered by:
1) little interest or pleasure in doing things?
2) feeling down, depressed or hopeless?
If yes is answered to either question, complete PHQ-9
What is decerebrate posture?
hands down and flexed out
What is Decorticate posture?
hands clenched and brought up towards body
What is Dysphonia?
voice is volume disorder caused by laryngeal disorder or impairment of X cranial nerve
What is Cerebellar Dysarthria?
irregular, uncoordinated speech caused by multiple sclerosis
What is Aphasia?
difficulty production or understanding language caused by motor lesion in dominant cerebral hemisphere
What is Wernicke Aphasia ?
rapid speech at lax meaning caused by lesion in posterior superior temporal lobe
What is Bracha Aphasia?
slow speech with different articulation, but fairly clear meaning caused by lesion in posterior inferior frontal lobe
What are the different mental status affects?
-Euthymic
-Constricted
-blunted
-flat
-labile
-inappropriate
What is euthymic?
Normal, steady, tranquil mental state
What is constricted?
A mildly diminished range or intensity of emotional expression
What is blunted?
Markedly diminished emotional expression
What is flat?
A severely reduced emotional expression
What is labile ?
Irregular and severe mood swings
What is inappropriate?
Emotional responses that are not in keeping with the situation or are incompatible with expressed thoughts or wishes, such as smiling when told about the death of a friend
What is Ericksons toddler stage
Autonomy vs shame/ doubt
Having control without loss of self esteem.
Negative Resolution leads do doubting of ability’s and feelings of shame.
Positive resolution leads to self confidence and will power
What is Ericksons preschooler stage
Initiative vs guilt
Sense of moral responsibility
Negative response leads to feelings of disapproval
Positive resolution leads to direction and purpose
What is Ericksons school age stage
Industry vs inferiority
Physical independence from parents
Negative response leads to feelings of failure positive response leads to competence performing tasks
Ericksons adolescent stage
Identity Vs role confusion
Emotional independence from parents
Fusing of several identities into one
Negative resolution leads to confusion and non focused.
Positive resolution leads to devotion and fidelity
Ericksons young adult stage
Intimacy versus isolation
Committing to relationships, whether their social or intimate
A negative resolution needs to loneliness and poor development of relationships
A positive resolution leads to affiliation in love
Ericksons middle-age stage
Generatively Vs stagnation
Giving back to the younger generation
A negative resolution leads to selfishness, shallow involvement in the world and a little psychosocial growth
A positive resolution is to production and care
Ericksons older adult stage
integrity versus despair
Acceptance of life lived as well as acceptance of death as it’s entity
A negative resolution leads to regret, discontent and pessimism
A positive resolution leads to renuncication and wisdom
Piaget’s theory of cognitive development
He focused on HOW a person learns not about what they are learning.
The process of obtaining an understanding about one’s world
Cognitive development occurs due to how someone organized and adapts to how they perceive their environment.
What is Piaget’s concept theory made of (4)
Schema
Assimilation
Accommmodation
Equilibration
What is schema
Thought, emotional, memory, movement of body or sensory experience 
What is assimilation?
When a stimulus or information is joined with an already existing schema
What is accommodation?
The creation or accommodation of a new schema
What is equilibration ?
Balance between assimilation and accommodation
What are Piaget’s 4 stages?
Sensorimotor
Preoperational
Concrete operational
Formal operational
What is sensorimotor
Age: 0-24 months total. Stages are broken up by age
Birth to 1 month: basic reflux (suckling)
1-4 months: discovers enjoyment thru random behaviors and repeats them (smiling or sucking thumb)
4-8 months: related own behavior to a change in environment (shaking a rattle and hearing sounds or moving a spoon to eat)
8-12: can coordinate more than one thought pattern to reach a goal (repeating throwing an object on the floor)
12-18: recognized permanence of objects even if they are out of site also can understand simple commands
18-24: begins to develop reasoning, and can anticipate events
What is preoperational?
When the use of symbols & language begin and pictures increase.
It’s divided into two stages:
Preconceptual (2-4)
Intuitive (4-7)
In preconceptual phase a word is assigned to several similar things (all 4 legged animals get called by their pet dogs name)
As they move into intuitive stage, they start to realize the ability of a certain word to represent a specific object
What is fundamental ecocentrism ?
Everything is as the child perceives it and doesn’t believe things can be different elsewhere
Ex: if I’m going to bed now, every child everywhere must be going to bed.
What is centration?
Tends to focus on one aspect of an object or experience
Ex: two rows 6 Pennie’s, one row has them spaced out more so child lays the longer row has more
What is limited transformation?
Cannot comprehend the steps of how objects can change
Ex ice melts to water
Action rather than abstraction
Perceives an event as if actually loving it again
Ex when asked about riding in a toy car, they may imitate turning the wheel
What is irreversibility ?
Unable to follow a line of reasoning back to the beginning.
Ex: retracing steps while in a walk
What is transductive reasoning ?
Things specific to specific - if two things are alike in one aspect the. They are alike in all aspects
Ex: seeing a beetle at the park is the same beetle in their backyard
What is Animism ?
Believes inert objects are alive with feelings and can thing and function with intent
Ex: vacuum is eating toys
What is concrete operational?
Age 7-11
Starts to think and reason logically about objects in the environment.
Reasoning is limited to concrete objects and events (what is) and not abstract (what might be).
Inductive reasoning has started and can start to consider viewpoints of others.
Can use a clock, understand weeks, months, year, math, organize, classify, capable of money management
What is formal operational?
Age: 11-15+
Starts to problem solve in real world and theoretical situation. Can think about past, present and future logically and flexibility.
Can think about symbols and abstractly. Can generate multiple solutions Can use deductive reasoning.
Kohlberg theory
Moral development that is influenced by cognitive structures.
Justice is the goal of moral judgement
Has 3 stages:
Preconventional
Conventional
Postconventional
What is preconventional (premoral)
Kohlberg’s 1st stage
*orientation to punishment and obedience
(Preschool - early school age)
&
*orientation to instrumental relativism (individual purpose)
(Late preschool - late school age)
Part one: hard to consider two points of view in a moral argument.
-Conforms to rules given by authority figures to avoid punishment
-punishment, obedience, reward are all involved in this level
-perception of good and bad develop
-punishment means action was “wrong”
Part 2: Starting to become aware that people can have different perspectives in a moral dilemma. Desires reward for “right” act
**viewed infants and young toddlers as naive and egocentric and not capable of moral reasoning
What is conventional stage? (Maintaining external expectations of others)
Kohlberg’s 2nd stage
*orientation to interpersonal concordance (unity and mutuality)
(School age - adulthood)
&
*orientation to maintenance of social order (law and order)
(Adolescent through adulthood)
Part one: Attempts to adhere to perceived norms. I wants to maintain approval and affection of friends and relatives. Wants to be considered “good person”
Part two: attempts to make decisions and behave by strictly conforming to fixed rules and the written law. “Rights of doing one’s duty”
What is postconventional? (Maintaining internal principles of self)
Kohlberg’s 3rd stage
*orientation to social contract legalism
(Middlescence - older adult *only 10-20% of dominant American culture attain this stage)
&
*orientation to universal ethical principle
(Middlescence - older adulthood *few ppl either attain or maintain this stage
Part one: rules and laws are changeable with due process. “Right” is respecting individual rights while emphasizing the needs of the majority.
Part two: making decision and behaving based on internalized rules, on conscience instead of social law
Things to collect for psychosocial, cognitive, and moral development during initial interview
Subjective
Objective
Biographical
Current health
Health history
Family history
Lifestyle and health practices
What are subjective/objective data findings regarding psychosocial (youth)
Self acceptance
independence from parents
Involved in close relationships
Good problem solver
Have social group
What are subjective/objective data findings regarding psychosocial (middle adults)
Have healthy life patterns
Satisfaction from seeing others grow
Long term relationship
Have stable home
Find pleasure in their profession
Take pride in family and accomplishments
Contribute to the community
What are subjective/objective data findings regarding psychosocial (older adults)
-Recognizes changes that are due to aging
-Maintain relationships with kids, grandkids, and relatives
-Has continued interest outside of self and home
-Adjust to death of relatives, spouse
-Find meaning of their past life and accept death as inevitable
-Review accomplishments
What are subjective/objective data findings regarding cognitive assessment (young adults)
-assume responsibility and make independent decisions
-self evaluated strengths and weaknesses
-identify and explore multiple options and outcomes
-seek career mentors
-have future realistic plans
What are subjective/objective data findings regarding cognitive assessment (middle adults)
-differentiate goals, wishes and realities
-identify factors that give life meaning and continuity
-share knowledge with others
-emotions don’t affect cognitive decision making
-seek new ways to improve knowledge
-adapt quickly to change and new knowledge
What are subjective/objective data findings regarding cognitive assessment (older adults)
-maintain maximal independence with ADLs
-look for ways to find satisfaction with life
-determine realistic plans for future including own mortality
What are subjective/objective data findings regarding moral assessment (young adults)
-states priorities when making moral decisions
-perceives having approval of family
-perceived having approval of peers
-perceive having approval of authority figures
-perceived having approval of significant other
What are subjective/objective data findings regarding moral assessment (middle adults)
-states priorities when making moral decisions
-focus more on law and order or individual rights when making a decision.
-express willingness to stop unhealthy behavior and change lifestyle patterns for a higher level of eill was
What are subjective/objective data findings regarding moral assessment (older adults)
-states priorities when making moral decisions
-view rules and laws as changeable using legal means
-makes decisions consistently on internalized rules and in terms on conscience
-believe in equality for every person
Normal vs abnormal findings of psychosocial assessment (young adult)
Normal:
-intimacy
-self efficacy
-close caring relationships
-adult friendships with parent and siblings
Abnormal:
-isolation
-cannot express emotions
-loneliness
-addictive behaviors
Normal vs abnormal findings of psychosocial assessment (middle adult)
Normal:
-generativity
-establish nurturing relationships
-mentoring / giving to future generations
Abnormal:
-stagnation
-has not accomplished developmental task
-unable to give to future generations
Normal vs abnormal findings of psychosocial assessment (older adult)
Normal:
-integrity
-thinks their life was good
-reminisced about life
Abnormal:
-despair
-not grateful for life
-bitterness
Normal vs abnormal findings of cognitive assessment (young adult)
Normal:
-uses sensorimotor thought and learning
-alert to both internal and external stimuli
-cognitive regression when stressed
-deductive reasoning
-interested in learning / does at own pace
Abnormal:
-cognitive arrest occurred
-difficulty with abstract thinking
-difficulty understanding info written in textbooks
Normal vs abnormal findings of cognitive assessment (middle adult)
Normal:
-readjust and modified goals
-increasing creativity
-provides mentorship
Abnormal:
-difficulty remaining current at work and meeting expectations
-not made adequate or realistic plans for future
-don’t have in depth explanations and rationale when teaching
Normal vs abnormal findings of cognitive assessment (older adult)
Normal:
-share expertise with others
-reminisce on life and tell stories
-gradual transitions
-demonstrates flexibility
-solidify concepts of life or death
-makes realistic decisions
Abnormal:
-profits from assistance from others with tasks such as taking meds or ADLs
Normal vs abnormal findings of moral assessment (young adult)
Normal:
-moral reasoning
-maintains expectations and rules of family, groups and society
-obeys laws and respect authority
-guilt can be a motivator to do the right thing
Abnormal:
-behaves solely for self satisfaction
-infringes on rights or comfort zone of others
Normal vs abnormal findings of moral assessment (middle adult)
Normal:
-positive personal moral choices
-learned from their mistakes
-challenges authority as young adult
Abnormal:
-maladaptive coping mechanisms
-fears authorities with hopes of not getting caught
Normal vs abnormal findings of moral assessment (older adult)
Normal:
-respecting individuals but emphasizing the need of the majority
-absolute justice is needed for every individual
-may be willing to risk external punishment
-speaks one’s mind
Abnormal:
-harming self or others
-try to avoid disapproval from others
How do you use clinical judgements regarding analyzing developmental level?
-identify abnormal findings
-cluster data
-look for opportunity to improve (relationships and mental health)
-assess risk for clients concerns
*violent behaviors towards self
*violent behaviors towards others
*risk for poor relationship
*risk for suicide
-assess clients concerns
*depended on individuals level of assessed development
*anxiety
*poor body image
*delayed development
*family dysfunction
What is domestic violence?
Pattern of abusive behavior in a relationship that is used by another to gain/maintain control over the other person
What is family violence?
Violent or threatening behavior, or another other form of abuse that co told a member of the family
Types of physical violence
Slapping
Hitting
Kicking
Punching
Burning
Types of emotional violence
Threats of harm
Financial harm
Harm to child or pet
Suicide
Harassment stalking
Insults and verbal abuses
Isolation
Intimidation
Mind games
Throwing objects
Types of sexual abuse
Incest
Rape
What are McCue’s 5 theories of violence?
1) Psychopathology
2) social learning
3) biological theory
4) family systems
5) feminist
What is McCue’s psychopathology theory?
People who do harm have personality disorders
What is McCues social learning theory?
Violence is a learned behavior from childhood
What is McCues biological theory?
Physiologic changes from childhood trauma, head injuries, or through heredity can lead to violent behavior
What is McCues family systems theory?
Violence grows through family system function, but Sime criticize this theory as blaming the victim
What is McCues feminist theory?
Male/female inequality in patriarchal societies leads to violence
What is Walker’s cycle of violence?
Criticism
Acute battering
Honeymoon
What happens in the criticism phase of abuse?
-the tension building phase
-abuser makes unrealistic demands that can’t be met. Then frustration leads to anger shoving or slapping.
*victim often blames themselves for not being able to meet the demand
What happens in the acute bartering phase of abuse?
Could be triggered by something minor, but results in violence lasting up to 24 hours. Victim can rarely stop abuser
What happens in the honeymoon phase of abuse?
Period of reconciliation. Occurs after violent episode. Abuser is loving and makes false promises to stop. Acts very attentive to victim until cycle starts over
What is the cycle of domestic violence?
Similar to walkers cycle, but with 7 stages:
Abuse
Guilt
Rationalization
“Normal” behavior
Fantasy
Planning
Setup
What are the short term effects of emotional abuse?
Shame, fear, confusion
Physiological: aches, pains, muscle tension
What are the long term effects of emotional abuse?
Insomnia, chronic pain, anxiety
What can happen to children experiencing emotional abuse?
Physical: chronic health conditions, impaired brain development, brain injury, sleep disorders
Psychological, isolation, fear, inability to trust, low self esteem, depression, worthlessness
Behavioral: Some regression, adolescent issues, substance abuse, delinquency, truancy, pregnancy, sexual risk taking, high chance of getting raped
Societal: cost for child maltreatment facilities, juvenile and adult criminal activity, mental Illness
What is intimate partner violence (IPV)
Physical, sexual, or psycho local harm by current or former partner.
What is the leading cause of murder and injury-related death for pregnant women?
IPV
What psychological effects do older adults experience if abused
Shame, fear, condition
This can lead to high levels of distress and depression. They can develop anxiety, helplessness and PTSD
What physical effects do older adults experience if abused
Insomnia, chronic pain, anxiety
Welts, sounds, injuries, nutrition and hydration issues, increases susceptibility to new Illness
How to assess for elder abuse
It can be difficult bc of persons isolation, fear of perpetrator, and inability to report bc of cognitive impairment.
Use EASI : elder abuse suspicion index assessment tool
What is school violence
Bullying
Cyber bullying
Punking
What is human trafficking?
People who are deprived of their freedom to leave the work and are exploited further by traffickers stealing any identity documents often wages
Could be :
Farm/factory/restaurant
Sexual
Drug mules
Child soldiers
Debt bondage
What are war crimes?
Crimes committed against “enemy” that are outside of the Genova code
Make sure when treating patients if war crimes assess for PTSD
Subjective data regarding violence
-examine personal feelings, believes, biases that may interferes with perception and interpretation of what is going in
-assess for physical, psycho, economic and sexual abuse
-observe others presence at visit and assess without them in room
What to obtain for medical history regarding violence
Biographical date
Present health hx
Family hx
Lifestyle and health practices
Gaining medical history for suspected child abuse
-establish reassuring environment
-be comfortable with questions
-be calm and accepting
-do not coerce
- know and understand developmental stage child is in
-be direct without leading
-avoid yes/no questions
Give little info in questions
What is HITS assessment used for?
Used to screen for IPV
Hurt
Insult
Threaten
Scream
What is abuse assessment screen ?
Used to screen for abuse
1) within the last year
2) since you’ve been pregnant
What is danger assessment?
Used to screen for risk of homicide based on violence in relationships
What is a SANE?
Sexual assault nurse examiner
Complete focused gyne exam is sexual assault is suspected
What to ask for COLDSPA regarding violence?
C: describe it (symptom) what’s happening?
O: when did it start?
L: where does it happen?
D: how long does it last?
S: how bad is it? Rate on scale from 1-10
P: when does it happen or timing?
A: anything make it better or worse?
What percentage of information needed to make a diagnosis is obtained through appropriate history taking and questions?
80%
What ages if pediatrics are susceptible to violence?
All ages
When during pregnancy are women more susceptible to violence?
During and after
What ages of older adults are more susceptible to violence?
55+
What should you examine on patent regarding violence?
General appearance, dress, hygiene
Mental status
Skin
HEENT
abdomen, GI
MS, neuro
How to set up a safety plan with patient
-ask have you/ do you questions
*bag packed, told neighbors and ask to call if the my hear something, have code word for kids, know where to go, removed weapons from home
-have they gathered following
*cash, SS card, birth certificates, drivers license, rent and utility receipts, bank account numbers, insurance policy and numbers, important phone numbers
What are the four broad categories of child a use?
Neglect
Emotional abuse
Sexual abuse
Physical abuse
What is culture?
Shared systems of values, believes and learned patterned of behavior
What do the cultural competence process ASKED?
Awareness
Skills
Knowledge
Encounters
Desire
What is minority?
Group with smaller population numbers
What is immigration?
Moving from one country to another
What is an immigrant
One that is not native born, or have not become a permanent resident, alien or new citizen
That are CLAS mandated?
15 standards created by national standard for culturally and linguistically appropriate services in healthcare
What are the 15 standard of CLAS?
1) all should receive care with cultural beliefs and practices honored, in preferred language
2) diverse staff
3) ongoing cultural and linguistic training
4) interpreter
5) provide verbal and written notice (in preferred language) that they have a right to an interpreter
6) compliance of interpreter
7) easily understood patient related material
8) written strategic plan
9) conduct clas practices
10) ensure race, ethnicity and language are in EHR
11( ensure bio info is correct and reviews and updated
12) participatory and collaborative relationships
13) conflict and grievance resolution
14) info available to public
What is stereotyping?
Oversimplified conception, opinion, or believe about an aspect of an individual or group
What is ethnocentrism?
Universal tendency of humans to think their ways of thinking acting, and believing are the best and only right ways
What is acculturation?
When someone gives up the traits of their culture of origin to adapt to another
Assimilation
Gradual adoption and incorporation of characteristics of the prevailing culture
Cultural diversity
The coexistence of a difference in behavior, traditions, and customs
Cultural imposition.
Someone imposing their cultural believes onto another
Cultural relativism
Belief that behaviors and practices of ppl should be judged only from within cultural system
Culture
Totality of socially transmitted behavior patterns, arts, beliefs, values, customers lifestyles
Enculturation
Natural conscious and unconscious condition no big process of learning accepted cultural Norma’s, values and roles in society
Ethnicity
Socially culturally and politically constructed group that holds a common set of characteristics that are not shared by others who are members of the group come in contact with
What is subculture?
A group of people, with a culture that differentiates them from a larger culture which they are a part of
What is worldview?
The way, individuals or groups of people look at the universe to form basic assumptions and values
What is the main purpose of assessing a patient’s culture?
To learn about the patient’s beliefs, and usual behaviors associated with their health and illness
Example: disease causes, caring, expected treatments, daily hygiene, food, preferences, and rituals, religious beliefs, related to healthcare 
What is the purpose of the musculoskeleton system?
To provide structure and movement for body parts
What is the purpose of bones?
Store calcium
produce blood cells
* red marrow
* yellow marrow, composed, mostly of fat
206 bones in body
What are the two types of bones?
Compact bone
Spongy bone
Characteristics of compact bone
Hard and dents
Make up Shaft outer layers
Characteristics of spongy bone
Numerous spaces
Ends in Center phone
What is the periosteum?
Covers the bones
Contains osteoplast and blood vessels to promote nutrition in the formation of new phone tissue
What are the three types of skeletal muscles?
Skeletal
Smooth
Cardiac 
How many muscles are there
650
What is a joint?
Where two or more bones meet
They allow ROM
What are the three types of joints?
Fibrous
Cartilaginous
Synovial
What is a fibrous joint?
An immovable joint that is Joined by fibrous, connective tissue
What is cartilagineus joint?
A joint join by cartilage
What is a synovial joint?
Synovial fluid fills the space between bones to help lubricate and promote sliding movement
How are bones in synovial joints joined
By ligaments
What are ligaments
Strong dance band of fibrous connective tissue
What is a bursae?
Small sacs filled with synovial fluid that cushion the joint
What is the temporomandibular bone?
Temporal bone and mandible
Opens and closes mouth
Protects and retracts jar
Move job from side to side
What is the elbow?
Ulna and radius of lower arm, and a humorous of upper arm
-Contain synovial membrane and several bursae
-Provides flexion and extension from
-supination and pronation of the forearm
What is the sternoclavicular?
The junction between the manubtium of the sternum in the clavicle
-no obvious movements
What is the shoulder?
Head of the humerus in the glenoid cavity of the scapula
-Has subacromial and subscapular brusae
-Fluctuation extension, abduction, abduction, circumduction, and rotation
Articulation of wrist
They are lined with synovial membrane
Flexion, extension, hyper extension, adduction, radial, and ulnar deviation
Articulation of the fingers and thumb
Lined with synovial membrane
Fingers: flexion extension, hyper extension, abduction, and circumduction
Thumb : Flexion, extension, and opposition
Articulation of the vertebrate
Flexion, hyper extension, lateral bending, rotation
Articulation with the hip
Flexion with knee flexed and knee extended
-Extension hyperextension, circumduction, rotation, adduction, abduction
Articulation with the knee
Flexion and extension
Articulation with the ankle and foot
Ankle: plantar flexion dorsiflexion
Foot : inversion and eversion
Toes: flexion, extension, abduction, and adduction
What are cultural and genetic variations regarding bones
African Americans: thicker frontal bones
Causations: thicker parietal bones
Radius and ulna length vary depending on ethnicity
How do vertebrae vary among ethnicities?
Most people have 24 vertebrae
11% of African-Americans have 24
12% of Eskimo and native American men have 25
What is osteoporosis?
Demineralization of bones causing them to become porous and fragile, making individuals more susceptible to fractures
Progressive with no symptoms
Who is mostly affected by osteoporosis
Women
(Highest in white females)
(lowest in black males)
What things to assess for nursing history regarding MS
-Pain
-Stiffness
-Are ADLs affected
-Diet/exercise
Current health concerns regarding MS
-History of present health condition or concerns
-Any recent weight gain
-describe muscle joint or bone pain
Questions for personal health History regarding Ms
-Any problems or injuries?
-When was your last tetanus and polio vaccine?
Family history questions for MS
-Do you have any family history of rheumatoid arthritis gout or osteoporosis?
Lifestyle and health habits regarding MS
-are you taking any medication?
-Activities that promote health of muscles and bones?
-Do you smoke?
Physical exam regarding MS system
Posture
Gait
Bone strength
Muscle strength
ROM
Ability to perform ADLs
Perform special test for CTS
What are bulge, Ballottememt, and mucmurray tests used to assess?
Knee
What is the bulge test?
Inspection for swelling on the knee.
Client in supine position. Use all of hand to firmly stroke the medial of me upward 3-4 times (this is to displace any accumulated fluid) then press on the lateral side of the knee and look for a bulge on the medial side
Abnormal: bulge of fluid appears on medial side of knee with small amount of joint effusion
What is a ballottement test?
Text large amounts of fluid in the knee.
Patient lays and supine position, firmly press, non-dominant thumb, and index finger on each side of the patella (This displaces fluid in the suprapatellar bursa) With dominant fingers push the patella down on the femur, feel for a fluid wave or a click.
What is McMurray’s test?
Used to test for pain or injury in the name of patient complains of giving in or locking
Client in supine position, ask them to flex one knee and hip. Placed an index finger of one hand on either side of the knee, and use other hand to hold the heel of the foot up. Rotate the lower leg and foot. A lot of really slowly extend the knee and notice if there’s pain or clicking.
MS system and older adults
slower movements
reduce flexibility
decrease muscle strength
reduced elasticity of tendons
joint capsule calcification
Bone density loss
Bone fractures
Osteoporosis
Stiffness
Kyphosis (exaggerated thoracic curve) is common
Bow legged due to decreased muscle control
How to test muscles
Test strength by applying resistance against the moving part if patient can’t move against resistant, ask him to move against gravity
Inspect and feel for palpable muscle contraction went in motion
What are abnormal findings regarding posture and Gait?
Slumped shoulders
Spine curvatures
Uneven, weight-bearing
Cannot stand on heels or toes
Toes point in or out
Client lips or shuffled
Has a wide gate
What are the three abnormal spine curvatures?
Lordosis
Kyphosis
Scoliosis
What is kyphosis?
Rounded thoracic, convexity and upper back
What is scoliosis?
Lateral curvature of the spine with an increase in convexity on the side that is curved
What is lordosis?
Lumbar spine drives inward
Note: some African Americans have larger gluteal prominence that tends to look like lumbar lordosis
What can cause flattening of the lumbar curvature?
Herniated, lumbar discs, or ankylosing spondylitis
What is the nudged test?
Testing for fall risk of falling backwards with being nudged
Stand behind client and put your arms around them on the gene sternum
Normal findings in the temporomandibular
-snapping in clicking can be felt in heard
-Mouth opens wanted to inches
-Jammu is literally wanted to cm
-full ROM
What are abnormal findings in the temporomandibular?
-Decreased ROM
-swelling
-Tenderness
-crepitus is felt when jaw is palpated in person has arthritis
-Decrease muscle strength
-grating can be heard on client has TMJ decision
-Like a full contraction with cranial nerve V
When would you feel crepitus?
In temporomandibular when patient has arthritis
What are abnormal sternoclavicular joint findings?
-Swollen
-red
-Enlarged
-Tender
-Information
What are some abnormal findings regarding spine
-any abnormal curvatures
-unequal height of hips
-compression fracture
-cervical strain
Abnormal findings in shoulder, arm and elbow
-flat, hollow, or less rounded shoulders
-Tenderness and swelling
-decreases ROM
-inability to shrug
Abnormal findings of the wrist
-swelling
-Tenderness
-Nodules
-cysts
-Ulnar deviation
What is carpal tunnel syndrome?
Tingling
Numbness
Burning
Pain with movement
Abnormal findings of the hand and fingers
Pain
Tenderness
Swelling
Short fingers
Deformities
Abnormal hip findings
Instability
Inability to stand
Deformed hips
Tenderness
Edema
Decreased Rom
Crepitus
Inability to abduct
What is crepitus?
A grating sound, or sensation produced by friction between bone and cartilage, or fractured parts of a bone
What are abnormal findings in the knee?
Knock knees
Bowed legs
Swelling above / next to patella
Tenderness and warmth
Bulge of fluid on medial knee
Abnormal findings of the ankle and feet
Laterally deviated great toe
Overlapping of toe
Inflamed bursa
No arches in feet
Calluses
Warts
What are the most common sites of Sprains?
Ankles
Going to perform a focused screening during MS
After General routine- any abnormalities require a more focused screening
Is client describes an ability to move a joint or talks about pain.
Make sure to test for symmetry, color, ROM, strength, carpal tunnel, knee tests, lasegue test, CTS, flick signal
What is the lasegue test?
Patient in supine position, raise one leg while keeping other flat. Raise up until just short of pain then have them dorsiflex their foot. Assess for pain
What is CTS?
Carpal tunnel syndrome
What is flick signal ?
Ask patient what they do when symptoms are worse in wrist (carpal tunnel syndrome)
If they flick their wrist like shaking a thermometer, may mean CTS
How to assess recent or short term memory?
Ask questions about things and events that are currently happening
Example: what they ate for breakfast
How to assess for remote memory?
Ask question to test long term memory.
Example birth date
How to assess for abstract reasoning?
Ask how an orange and an apple are different
How to assess chief complaint?
Ask why they are at the clinic
What is Dysarthria
Slurring. A defect in muscular control a speech related to lesions of the nervous system, Parkinson’s disease, or cerebral disease
What are the rating scales for muscle strength.
5: active motion against full resistance / normal
4: active motion against some resistance / slight weakness
3: active motion against gravity / average weakness
2: passive ROM (gravity removed and assistance is used) / poor ROM
1: slight flicker of contraction / severe weakness
0: no muscular contraction / paralysis
What tests do you use to assess carpal tunnel?
-Phalen test
-Tinel sign
-flick signal
-thumb weakness
What is the tinel sign
Tests for carpal tunnel
Use finger to percussion lightly over the median nerve (located in inner aspect of the wrist)
Any tingling or shocking sensation
What is the Phalen test
Assess for carpal tunnel syndrome
Have client place the backs of both hands against each other while flexing the wrists 90 degrees with fingers pointed downward and wrists dangling. Hold for 60 seconds
Assess for tingling, numbness, burning or pain
